well hello everyone i'm dr leslie kerneson i'm a board-certified geriatrician and the founder of betterhealthwhileaging.net in this video i'm going to explain something that i wish all older adults and their families knew more about which is what doctors should check if an older person develops memory loss or thinking problems because yes if you have noticed memory loss or thinking problems in an older person that is not normal it absolutely should be medically evaluated and in fact the initial evaluation can be done in a primary care office you just need to know what to ask for
now you may be wondering do these memory changes warrant going to the doctor especially if it feels like it's going to be a hassle to get the older person there and i get that people wonder that because there are two really common myths about memory problems and aging that are pervasive not only among the general public but even among doctors the first is that memory loss or thinking problems are normal aging it's normal to develop a poor short-term memory as you get older or to have difficulty this is not true that is a myth the
other myth that you shouldn't fall for is that there is nothing to do because memory loss can't be cured or reversed some people might even think that there's nothing to do because they've heard that memory loss might be alzheimer's or another form of dementia and that that's not curable but that also is false both of those are really myths that you shouldn't fall for the problem however is that even many practicing doctors believe these myths and so even when an older person comes to the doctor reporting memory loss or thinking problems or actually what's more
common is that their families convince them to come in and bring up the memory loss and thinking problems of the doctor it's really common that people are told by the doctor that oh it's normal aging or what you expect you're getting older or maybe that okay that's not normal but there's nothing to do this really bothers me because it's wrong memory loss and thinking problems do indeed become common as people get older but they should never be considered normal they are the sign of a health problem affecting the brain and although it's true that some
people are experiencing symptoms of a non-curable brain disorder such as alzheimer's disease or another form of dementia there are many other health problems that can affect brain function and some can be treated even people who actually do have alzheimer's may have an additional medical problem that is keeping them from thinking as well as they otherwise could and it's really important to identify those and treat them so we can help older adults think their best and live their best lives so in the rest of this video i'm going to do two things first i'm going to
take you through what i would say are the 10 most common causes of memory loss and thinking problems in older adults so that you all have a better understanding of what might be causing an aging brain to malfunction and then i'm going to take you through 10 things doctors should do to evaluate an older adult experiencing cognitive symptoms as part of that initial evaluation which can happen in a primary care office that way once you get to the doctor you'll know what to expect and what to ask about now i'm going to cover this in
the video but if you would like to review this information in more detail or maybe review it written out afterwards i'm going to post a link in the description below to a full article i've written on my website betterhealthwhileaging.net where you can get lots of information in detail and also links to related articles we have on the site and so now we're going to go into these 10 causes but before i tell you about them i want to emphasize something that's really important to keep in mind when it comes to memory loss and thinking problems
and to the health care of older adults in general what you want to realize is that when an older person's memory or thinking aren't working quite right and we call that cognitive impairment in most cases it's going to be multi-factorial so usually there's not just one cause that's causing all the problems most older people are actually experiencing several things that are keeping their brain from working at its best so as we go through these 10 common causes keep in mind that often we're not looking for the one smoking gun we're looking to see which of
these might be the cause or otherwise making things worse let me now take you through the 10 causes that i think about when an older person has started experiencing memory loss or thinking problems in no particular order i generally start with medication side effects so it turns out that many commonly used medications interfere with brain function so especially if you're concerned about memory loss or brain function it's really important to identify these medications and if an older person is taking them try to stop them or reduce them and many of these medications that affect brain
function are available over the counter probably the most common one that i see older people taking that's available over the counter is something like benadryl or something related so a sedating antihistamine these are often the pm component in a pm painkiller that you'll find over the counter like in nyquil or tylenol pm they're also available in over-the-counter sleep aids so these medications are what we call anti-cholinergic they interfere with transmission of neurotransmitters in the brain and you need that to think at your best other medications that also slow down brain function include other sedatives and
sleeping medications tranquilizers or medications that people sometimes take for anxiety or for their nerves and then there are many other medications that are anticholinergic such as medications for overactive bladder and a few other types of medications so identifying these is important if we want to help an older person with their memory loss and sometimes can make memory loss or thinking much worse so the next cause that i want to talk about is what we call in medicine metabolic imbalances so i wasn't sure how to come up with the non-medical term for this but it basically
means abnormal levels of some components of the blood chemistry often an electrolyte in the blood chemistry the ones that we most often see out of whack in older adults are blood sodium blood calcium or blood glucose so if any of these are too high or too low it can cause confusion in older people or slow down their brain function and cause them to have symptoms another cause of metabolic imbalances in older people and in people who are younger for that matter would be kidney dysfunction or liver dysfunction that's in part because the kidneys and liver
often play a role in regulating your blood chemistry but also in of themselves if they're not working quite right the body can accumulate certain things in the bloodstream that can keep the brain from working at its best how do we check to see if an older person might be experiencing one of these problems normally that's done through blood work often quite routine blood work the third cause that i think about is problems with hormones and especially in older adults in geriatrics we think about could the person be experiencing a low level of thyroid hormone that's
probably the most common cause of memory loss or thinking problems related to hormones that we see in older adults now it's also possible to have brain function affected by imbalances in estrogen or other sex hormones this is something that i would say affects people probably more in midlife so we don't see it as much in geriatrics practice where we're often taking care of people who are in their 80s and 90s but that would be something to consider for a middle-aged person and you know could potentially be an issue in an older person the fourth cause
that i think about is vitamin deficiencies and especially i think about vitamin b12 deficiency because it is fairly common in older people and vitamin b12 is very important to brain function depending on the person's situation we might also consider whether they're experiencing low levels of other b vitamins or folate now of course the body needs many other vitamins to function optimally and it's possible that those could affect the brain as well but we don't usually routinely test for them in particular there's been a lot of interest in vitamin d these past several years but even
though it's been studied often giving people extra vitamin d doesn't seem to help improve a cognitive symptoms so i don't particularly check for vitamin d if i'm concerned about memory loss or thinking problems in an older person now for number five number five on my list is delirium this is a biggie because it's very common in older adults especially if they have recently been hospitalized or undergone surgery or a major illness so what is delirium delirium is basically a state of worse than usual mental function that is brought on when the body experiences a significant
stressor so sometimes it's referred to as hospital dementia or icu psychosis and that's because the stresses of hospitalization or when people are sick enough to be hospitalized or have surgery those are the situations in which you can generate a big enough stress on the body for people to experience delirium now as people become older and frailer they can actually develop delirium even if they're not that sick and so we do sometimes see it in the clinic but what's important to know is that delirium can cause someone who's usually normal to behave like someone who's psychotic
or very confused or has alzheimer's or another form of dementia also although delirium symptoms often get better as people recover from their hospitalization or surgery it's important to know that it can take weeks or longer for it to fully resolve in an older person and sometimes people never get back to quite the way they were before so if i hear about memory loss or confusion in an older person i always want to know if they've recently had a hospitalization or surgery or another major illness so that i can think about whether delirium might be contributing
to the situation now for number six number six on my list is psychiatric illnesses so most major psychiatric conditions can cause problems with memory thinking or concentration so especially depression depression can affect memory and concentration and some older people even develop something that's called psychotic depression where they can become frankly delusional or really seem very abnormal due to depression anxiety is another condition that is not uncommon in older adults generally we wouldn't expect that to cause frank delusions but it could cause difficulties in concentration or sometimes memory especially if the anxiety is affecting an older
person's ability to sleep and they're not well rested it's also possible that some older adults have another form of serious mental illness such as bipolar disorder or schizophrenia but in many cases they have already been diagnosed with that earlier in life so in general if an older person has been experiencing memory loss or thinking problems i always want to ask about symptoms of depression or anxiety and ask about their mental health history to see if a mental health issue might be contributing to the symptoms we're concerned about number seven on my list is substance abuse
and or withdrawal so by substances i mean things like alcohol drugs or even prescription medications such as sedatives or painkillers these definitely affect the brain and the brain can definitely be impaired and not able to function well if people are intoxicated and currently under the influence or their brains can also be affected by chronic overuse basically chronic damage due to the substance and that's something we see especially with people who are chronic alcoholics but also if a person is used to using alcohol every day or their prescription medication every day and they're not able to
use it they can experience withdrawal and withdrawal in of itself can cause confusion thinking problems and brain dysfunction so when i'm considering what might be causing memory loss or thinking problems i always want to know does this older person use any substances regularly or is there a possibility they could be withdrawing from something next number eight number eight on my list is damage to brain cells due to injury and the most common form of injury that i think about is what we call vascular damage so vascular refers to the blood vessels of the brain and
just as you have blood vessels throughout the body and a network of blood vessels for the heart we also have a network of blood vessels for the brain and the brain very much needs the oxygen that comes in through the blood vessels so if there has been damage to those blood vessels that damages brain cells and that can cause memory loss and thinking problems if it's been a major blood vessel that was damaged that would be a major stroke and often people have obvious symptoms at the time they are having that stroke but it's also
possible for the teeny tiny blood vessels in the brain to experience damage for various reasons often for reasons that are very similar to the reason why people develop heart disease high blood pressure high cholesterol sometimes diabetes lots of inflammation lots of stress smoking and so when the small blood vessels in the brain are affected in this way and get damaged the brain cells around them can be damaged and this is sometimes called cerebral small vessel disease and if enough of the brain is damaged in this way it can cause memory loss and thinking problems so
that's one form of damage to the brain cells that is due to injury that i think about the other would be head injuries which can cause temporary or long-term brain function impairment so when i'm considering whether this is an issue i consider the age of the person their past medical history and we might consider a scan of the brain to see if we see signs of damage in that way too i also ask if there have been any head injuries next number nine on my list would be damage to brain cells due to neurodegenerative disease
now this is number nine but it is quite quite common for people as they get older if they are lucky to get old enough to start experiencing some neurodegenerative diseases so what are these conditions these are conditions that basically accumulate usually in the brain and slowly damage and kill neurons over time usually over years so these are diseases that take 10 20 years often to have to show symptoms and then for the symptoms to progress you've heard of the most common neurodegenerative diseases they are things like alzheimer's disease and parkinson's disease there are also other
ones like lewy body disease and frontotemporal degeneration these conditions are often the underlying cause of conditions such as mild cognitive impairment which means a person is having some memory or thinking problems but they are not bad enough to interfere with day-to-day function and then there's dementia which is an umbrella syndrome describing a condition where people's brains have changed to the point that it's a permanent change and they have lost independence in some daily life tasks and it's not due to a psychiatric condition or something reversible and alzheimer's disease is the most common underlying cause of
dementia so that would be another potential cause of memory loss and thinking problems in an older person and then number 10 on my list is infections so this i would say is less common but does happen so basically certain acute which means they're happening right now or chronic which means they've been going on for weeks or months certain acute or chronic infections can affect brain cells directly and the cause might be viruses bacteria parasites a fungus so we don't routinely in geriatrics evaluate people for these kinds of brain infections unless they're showing other symptoms or
unless they've suddenly become quite ill and honestly when memory loss or thinking problems come on very suddenly we usually have a another way of thinking about things than if it's been going on for months or years and slowly getting worse which is the situation i mostly have in mind right now now you may have heard of people developing memory loss or thinking problems because they're sick from an infection like a pneumonia or a urinary tract infection this does happen but in that case we think of it more as an example of delirium rather than a
direct infection to the brain because that's usually what's going on so those are the 10 causes that i think about the most when i'm considering memory loss or thinking problems in an older adult now i do want to acknowledge one more cause it's not something we think about it's not something we evaluate a lot in geriatrics but it has been brought to my attention and i think it's you know reasonable to have it on the list which would be toxins so by toxins i mean things like heavy metals air pollutants water contaminants pesticides these are
another potential cause of problems with brain function in aging but in geriatrics and i would say kind of mainstream medicine and i personally aim to practice the best of geriatrics and the best of mainstream medicine for older adults we don't routinely check for these toxins there's a lot of interesting research going on it's also not clear right now how you would remove them or or treat them so it's not part of my routine evaluation but you may hear other people mention it and that is why so those were my top causes of memory and thinking
problems in older adults and as you saw there are many medical conditions that can affect brain function so if you notice problems with memory or thinking in an older parent or another older loved one or even yourself it's really important to get a medical evaluation so that these can be checked for so now let me take you through what i believe doctors should check when an older person is brought in from memory or thinking problems these recommendations are based on my practice and the practice of most geriatricians and are basically in line with what the
expert guidelines recommend for evaluation of cognitive impairment in an older person because basically what we want to do is check for those common causes that we just talked about to help rule them in or out so here's my list first what the doctor should do is ask about and document the older person's concerns about their memory and thinking now this can be tricky in that many older people are either unaware that they're having memory loss or thinking problems or they are denying it or they're defensive and get upset when it's brought up so it often
requires the doctor to be tactful about uh asking about it there are tactful ways to ask but it's very important to understand for the older person what's their awareness of the problem and how do they see it what are they most interested in or concerned about it's also important to compare their perception of the problem with the perception that is reported by other people other family members and with what the doctor observes so that's definitely an important element the next element that's important is for the health provider to get or request information about any signs
of memory loss or thinking problems from other people other family members like the spouse or someone else who lives with the older person or other what we call informants which are basically people who've had a chance to see the older person in their usual circumstances and might be able to provide information now i have found that often doctors don't get around to doing this it might be because the older person came to the appointment alone or didn't want anybody with them and they're not sure how to go about doing it but it's really important for
them to try to get this information because an older person who is experiencing memory loss or thinking problems is not a reliable reporter of what is going on with them so it's really important to get that information also you should know that it is not a hipaa violation for doctors to try to get this information and it's not a hipaa violation for them to receive this information from you as family so if you take a look at my related article on better health while aging i'll have a link to my article on hipaa and family
because many people in the public don't understand hipaa and actually many health providers don't have the details quite right on what hipaa allows them to do and doesn't allow them to do but basically you can always tell a doctor what you have observed because you as a family member are not a covered entity required to observe hipaa rules the covered entities are basically healthcare professionals insurance companies those of us whose work is healthcare and then a doctor should not be disclosing all of the older person's health information to other people without their permission but they
certainly are allowed to ask as part of an evaluation if other people have noticed anything or have anything to share or contribute that is not a hipaa violation so this is an important thing and if it's if you are concerned about somebody who has memory loss or thinking problems i want to let you know that you are allowed to relay what you've observed to the health provider you just want to think about doing so diplomatically and ideally the older person you're concerned about would be agreeable to to you doing so okay so number three on
my list is that the doctors should ask about any difficulties managing daily life tasks so in geriatrics we call this assessing function so how is the person functioning in their daily life and the two big buckets that we consider are activities of daily living and instrumental activities of daily living so really briefly activities of daily living are the basic skills that we often learn in early childhood walking talking getting dressed feeding yourself getting to and from the bathroom bathing and instrumental activities of daily living are the higher level skills that we learn as teenagers that
are usually required to live independently as an adult so that includes things like driving or managing transportation finances grocery shopping meal preparation home maintenance managing medications as you can imagine if a person is having difficulty with memory or thinking it is often the instrumental activities of daily living that are affected first and so health providers should really ask they can both ask the older person have you been having any trouble with any of your usual activities or are you getting any help from anyone with anything and of course they should ask a family member or
an informant because again the older person may not be a reliable reporter of what they need help with understanding how the person's daily life is affected is matters both in terms of making a diagnosis or edging towards one diagnosis or another if it's a question of mild cognitive impairment versus dementia but also it signals what the older person might need help with and support with or where there might be safety issues so i think it's very important number four on my list would be that the health provider should check for other signs of behavioral mood
or thinking symptoms so this is often related to are there signs of mental health issues or are there certain behaviors or signs that might point us towards one type of cause of cognitive impairment or another so specifically they should try to find out either from the older person or from family if the older person has been experiencing things like hallucinations delusions personality changes apathy depressive symptoms anxiety symptoms getting lost visual spatial problems if you would like a longer list of signs and behaviors that are often associated with memory loss and thinking problems i'm going to
be recording soon a related video 21 signs to look out for and i have a longer list right there that you can go through so next on my list number five the health provider should ask about any new symptoms or changes to physical health again we're kind of trying to piece it together with could these memory loss or thinking problems reflect another problem with the body somewhere else it's especially useful to ask about neurological symptoms such as new problems with walking new problems with balance new problems speaking or new problems with coordination number six the
health provider should try to find out if there are any concerns about substance use and consider the possibility of abuse or withdrawal so again this means inquiring with the older person about their use of alcohol drugs prescription medications and also probably checking with family or others number seven on my list very important i would say is to review all medications and focus on those that affect brain function so especially the sedatives and tranquilizers and those anticholinergics those over-the-counter antihistamines or sedating medications that interfere with brain function and also looking out for the other anti anticholinergics
that are often prescribed for overactive bladder or for other causes again i have a list of seven types of commonly used anticholinergics which is one of the links in the article related to this video if you want to know more about those and unless you think this is not important i can think of many patients where when we identify those medications that affect memory and we reduce them the person's memory and thinking really did get better so i think it's something very important and totally doable in primary care number eight is that the health provider
should perform a physical examination and what exactly they they examine is going to depend you know the details they found out so far but generally you want to include a basic neurological evaluation especially of the nerves related to the face and head and neck because those are all nerves are related to brain function but those have particular importance in evaluating memory loss and thinking problems and the provider should also ask the older person to stand up and watch how they walk have them walk across the room turn around and and see it's also a good
idea to check for what we call parkinsonism symptoms they're associated with parkinson's disease but can also be associated with related conditions such as lewy body dementia and for that it's checking for a tremor and in parkinson's the tremor is at rest not when people are moving trying to do something but when they're at rest when their hands are in their lap for instance so it's looking for a tremor there and then checking to see if they feel stiff in the arms or other limbs other things that would be looked for on the physical exam are
again going to depend on the person's past medical history and what else has turned up you know in the investigation number nine uh for the evaluation is to specifically do some office based testing of the person's memory and thinking skills so i would call this assessing their orientation and then doing a short office based cognitive test so in medicine orientation means does the person know the date the day the month the year where they are and who they are and i look at notes and often the providers have not specifically assessed this you really have
to ask the older person you know i often say i'm going to ask you a few basic questions they might seem a little silly and then there's doing a few one of not a few generally you just need to do one but there are a number of short office based tests that can be done to test memory and thinking so probably the shortest one that's well validated is called the mini cog so that involves asking them to remember three items you tell them three items and later you ask them again and having them draw a
clock and place the hand at a certain spot so that doesn't take a lot of time and then there are other tests that can be done with pen and paper they usually take 10 to 15 to 20 minutes the truth is they take longer when people are having memory loss and thinking problems if you give them to somebody who's young and fine they go quite quickly but those would be tests like the the mocha montreal cognitive assessment the slums st louis university mental state exam or even the minty excuse me the mini mental state uh
exam that's an older test which is now considered a little less good so we don't use it very often in geriatrics but some providers are still using it and then number 10 on my list of what should be done would be that the health provider should order laboratory testing and consider brain imaging so i think it's a good idea to get blood tests unless they've been done very recently and so what specifically is ordered is going to depend again on the specifics of the situation but generally checking a complete metabolic panel which would include blood
electrolytes liver function kidney function checking vitamin b12 levels checking thyroid tests and then potentially there could be additional tests like a complete blood cell count if there's concern for an infection or another type of illness that would be relevant to that test it's also fairly common for people to order a brain cat scan or brain mri mri is better for showing the details of the brain when it comes to memory loss and thinking problems but it does require sitting in the scanner for a good 45 minutes which can be hard for some older people who
are having memory loss or thinking problems on the scan it can it can show a variety of things what it will often show are signs of some uh small blood vessel damage to the brain that is extremely common in older people most older people have it actually if you scan their brains and it has imperfect correlation with actual symptoms so one of the things that i often tell people is that you can't really definitively rule in or out any cause of memory and loss of memory loss and thinking problems with the brain scan alone you
know it's a piece of the puzzle but it shouldn't be it shouldn't be the only thing done and these other things are not done that's really not adequate so those are the 10 things so really if if you put it together we kind of need four things to happen during this medical evaluation one is we need the health providers to document the patient and family's concerns it should be in the chart that some concerns about memory and thinking problems have been brought up and what they specifically are right so you know either what the patient
has noticed themselves that they're concerned about or what the family has noticed in terms of memory loss symptoms or thinking problems next they really should document any difficulties that the older person is having in their daily life tasks again because if the person is having a lot of difficulty we need to think about how can we provide more support or assistance it might also make it more urgent to get other family members involved third during these evaluations we want the health providers to do their own objective assessment of the patient's memory and thinking abilities even
if it's something quite brief like just finding out if they know where they are the day and date who they are and whether they can do some you know fairly basic things like remember a few words and draw the clock and then lastly the health provider should really do that initial evaluation for common medical causes and contributors to worse brain function so especially the medication review possibly the basic labs and checking for a few of those other medical causes that i mentioned is this going to lead to a definitive diagnosis not necessarily but it's an
important starting point and it shouldn't be delayed so again if you're wondering how do you get this evaluation i want to tell you that you do not have to wait for months to get seen at a special memory center for this this all this initial evaluation can be done in primary care and i would say should be starting primary care now it's extremely hard to do it in just one visit unless the clinic is really prepared for these kinds of evaluations it is often going to take at least two visits but it is doable in
primary care in short if you've gone concerned about an older person's memory or thinking i hope you won't believe those two myths that you know it might be normal aging or that there's nothing to do now you know what are the potential causes and now you know what should be done as part of a medical evaluation so i hope this will help you um or your loved one get the evaluation that they need if you want more details be sure to check out my related article you can even print it out and use it as
a resource and if you did find this video helpful please subscribe since i plan to continue to make videos related to memory loss and other age-related health challenges so thank you so much take care thank you for watching and i'll see you hopefully in another video
